Update on “Totally Drug Resistant” Tuberculosis

Last week, I discussed the breaking news of an emerging strain of “totally drug resistant” tuberculosis (TDR-TB)* in Mumbai. This week, the Indian government denied the findings, arguing that the twelve cases were in fact extensively drug resistant (XDR, not “extremely,” as I wrote previously). The Ministry of Health and Family Welfare stated that nine of the twelve patients were responding to treatment, while the other three had died. Furthermore, the Ministry said that the diagnostics lab at the Hinduja National Hospital, where the twelve patients were treated, was not accredited to diagnose XDR or TDR cases.

The Ministry also pointed out that the World Health Organization (WHO) does not recognize the classification of “TDR” at this time. In an article written this month, the WHO explains that current drug susceptibility tests cannot determine with enough certainty whether a strain is XDR or TDR to make a solid conclusion. The WHO will meet in March to discuss TB drug susceptibility diagnostics and whether, or how, to define TDR-TB. The author of the study claiming the emergence of TDR in India, Dr. Zarir Udwadia, argued that this was not the time to parse words, saying: “Let them call it what they want. For physician and patient, it’s not just a question of semantics–it’s a question of survival and mortality.” In more concerning news, Business Week published an article today detailing that ten more possible cases of TDR (or XDR) TB have emerged 250 miles (400 kilometers) south of Mumbai. Indian and WHO officials are meeting to discuss what to do, including the possibility of mandatory quarantines.

Whether or not it’s fair to use the TDR moniker, drug resistance is a serious, emerging issue that may very well define the next stage of global health. The appearance of multi-drug resistant (MDR) and XDR TB, MRSA strains, and other drug resistant pathogens in the past couple of decades or so, has shown that despite the great strides we have made since the discovery of penicillin in the last century, life will find a way around the miracle drugs we have developed (about which I wrote in September 2011, including Dr. Fleming’s concerns in 1945). More aggressive quarantine protocols and drug adherence strategies must be discussed, for a start. This in itself is a fraught notion, as it raises questions about patients’ rights and freedoms, stigma of and discrimination against people diagnosed with drug resistant pathogens, and similar issues. Better diagnostic tools must be developed and rolled out globally, with particular attention paid to developing nations, where need, disease burdens, and non-adherence are often greatest. More efforts must be made to strengthen overburdened and underfunded health systems, particularly in the developing world, and to effectively train health care workers to diagnose, treat, and support patients with pathogens that may become, or are, drug resistant. Finally, pharmaceutical companies must make new drugs more widely available and affordable, while stepping up development of new drugs. These last three points, of course, have been sticking points for almost every global health issue for a long time and continue to plague disease prevention, treatment, and eradication efforts worldwide. We are reaching a turning point, one at which some drug resistant pathogens are on the cusp of shifting from a handful of cases, an endemic, to a bigger, epidemic or even pandemic problem. Now is the time to initiate discussions on what the global community will do to stem drug resistance.

*If you want a bit more information on TDR-TB, take a look at the WHO’s page on TDR, or check out The Los Angeles Times‘ interview with Dr. Otto Yang of the UCLA medical school. Discussions of (and mild panic about) drug resistance, especially for TB, have been around for years–check out John Le Carré’s novel The Constant Gardener or its excellent film adaptation for a little MDR-TB/Big Pharma/international conspiracy thriller on the topic.

Author

Julia Robinson

Julia Robinson has worked in South Africa at an NGO that helps to prevent mother-to-child transmission of HIV and in Sierra Leone for an organization that provides surgeries, medical care, and support to women suffering from obstetric fistula. She is interested in human rights, global health, social justice, and innovative, unconventional solutions to global issues. Julia lives in San Francisco, where she works for a sustainability and corporate social responsibility non-profit. She has a BA in African History from Columbia University.